speech and memory problems

How Early Memory Loss Shows Up in Everyday Speech

Conversational cues may arise sooner than other signs of mental decline.

If your memory seems OK but your speech is slipping – you can find the car keys but not always your words – should you be concerned? Possibly so, according to a new study. Among a group of adults in late middle age who were functioning fine in their day-to-day lives, those whose conversational patterns declined most during a two-year period were more likely to develop mild cognitive impairment .

[See: 5 Ways to Cope With Mild Cognitive Impairment .]

It's perfectly normal to use fillers like "um" and "ah" in your speech, says Kimberly Mueller , an associate researcher at the University of Wisconsin–Madison and lead author of the study presented in July at the Alzheimer's Association International Conference in London. It would take a much more marked deterioration in fluency and syntax to possibly foreshadow a progressive loss of memory and eventual dementia .

Having a word on the tip of your tongue is a common experience . However, when retrieving words takes longer and longer, or someone can't retrieve words at all, that's significant. Repeating sounds and filling pauses with "um" more and more frequently as time passes is another telling sign.

"It does become harder to retrieve words in normal aging," says Mueller, who is a speech-language pathologist . "But the problems we see in mild cognitive impairment and dementia are so severe that they happen multiple times, even in one or two sentences. And often the message is just lost and [people] can't get their thoughts across."

Participants for the study had previously enrolled in the Wisconsin Registry for Alzheimer's Prevention. Launched in 2001, WRAP is believed to be the largest long-term study of healthy people who have a family member with Alzheimer's disease , putting them at higher risk of developing dementia themselves.

An unexpected finding in the new study, which included 264 at-risk adults from the larger WRAP group, was that participants found to have early MCI performed higher on syntax at the study's start. That was analyzed from a one-minute speech sample after they were asked to describe a simple picture.

However, at the repeat speech analysis done at the two-and-a-third year mark, their speech had declined more steeply than for those adults with stable cognitive health. That drop in language ability correlated with development of early mild cognitive impairment in 64 participants, based on up to 10 years of follow-up testing.

Identifying these conversational cues at home might be important for getting people to seek help sooner. "If it is noticeable and interfering with socializing or with getting needs met, then it would be worth going to your doctor and talking about that," Mueller says. That could prompt further screening for cognitive impairment, she adds, as well as a discussion among health care providers, patients and families.

How to Identify Alzheimer’s Symptoms

Jessica Leigh Zwerling, M.D. Aug. 16, 2016

Portrait of senior couple with closed eyes, close-up.

Recording snippets of conversation during regular doctor's visits could potentially serve as a new type of screening tool to pick up mental changes sooner than current methods, Mueller says. Speech comparisons and analysis done from one visit to the next might provide a quick, simple and inexpensive measure of cognitive ability over time.

[See: Easy Ways to Protect Your Aging Brain .]

Once dementia is diagnosed and has progressed, speech deterioration becomes more obvious. Different types of dementia cause different speech problems, says Dr. Ken Brummel-Smith , a professor emeritus with the department of geriatrics in the Florida State University College of Medicine. With Alzheimer's, he says, speech-related issues usually don't occur until the middle stages.

Conversational problems tied to memory loss often show up before actual language changes. People "often make things up, and especially if they're very social, they have pretty ingenious ways of getting around the fact that they don't remember something," Brummel-Smith says.

He recalls working with a patient and trying to perform a mental status test. Whenever the patient was asked who the current U.S. president was, a standard test item, she would say, "They're all crooks; I don't pay attention to that anymore," to cover her memory lapses.

In terms of language, Brummel-Smith says, "Usually, the first change in Alzheimer's-type dementia is anomia: difficulty remembering words. The next thing is [people] start saying words incorrectly."

In this stage, known as paraphasia, if an evaluator held up a wristwatch, for example, someone with dementia might respond with "clutch," combining the words watch and clock . "They'll often try different sounds until they hear something that sounds right," Brummel-Smith explains.

Neologisms – made-up words that are completely indecipherable – mark the nadir of language decline. Unfortunately, Brummel-Smith says, a person at this stage may only be able to say one or two words, frequently cry out, moan or make guttural sounds.

With a less-common type of dementia called primary progressive aphasia, language problems start before memory problems arise. People can still function intellectually at this point, Brummel-Smith says. He recalls a case of a lawyer who could still write fluently but had difficulty speaking and others had to take on his court-related trial work. Eventually, he progressed to dementia.

Whatever the type of dementia, Brummel-Smith says, language deterioration is similar in final stages.

[See: How Music Helps Patients With Alzheimer's Disease .]

Some family members and caregivers instinctively "get" how to talk to people struggling with dementia. Others might benefit most from interventions to improve their communication, for instance by working with a speech-language pathologist.

Helpful strategies include using simple sentences, bringing instructions down to single steps rather than multistep commands and, when appropriate, accompanying spoken language with a gesture, like pointing to your eyes when talking about them.

On the other hand, making comments like "I told you 100 times" is counterproductive after someone asks the same question over and over, Brummel-Smith says. "They don't remember being told the first time," he points out. Scolding born of frustration just raises their levels of anxiety and anger.

Accepting that loved ones have a brain disorder that doesn't allow them to do what they used to do is key, according to Brummel-Smith. "They can't change," he says. "They don't have the brain power to make a change. But we can always change for them."

9 Habits That May Reduce Your Risk for Developing Alzheimer's

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How Can A Speech Therapist Help With Memory Issues?

Your memory is important for your everyday life in ways you might not even realize.

Of course, your memory keeps facts in your brain, like your next meeting, if you’re picking the kids up from school on Wednesday, or who the president was in 1979.

(it was Jimmy Carter, by the way)

It also helps you remember how to do things, like type on your keyboard or brush your teeth.

Even knowing everything your memory does for you, it might surprise you that attending a speech therapy clinic can help with your memory problems.

Because speech and memory are tied so closely together, your speech therapist is an excellent person to go to if you or your child are experiencing memory problems.

What Actually Is Memory?

Simply put, memory is your ability to recall information that you’ve previously encountered.

Your memory is important for learning because it lets you draw upon information you’ve learned.

Your memory also allows you to recall this information in a timely manner.

What Is Working Memory?

Working memory is one type of memory that everyone has.

Your working memory lets you hear information, interpret it, understand it, and then use it to complete a task.

You use your working memory when completing simple mental math.

For example, if someone asks you what six plus six is, you use your working memory to listen to what they’re saying, interpret the math problem, calculate, and answer.

What Is Word Retrieval?

When you think of a specific word at the time you need it, that’s word retrieval.

You’ve probably experienced the feeling of being stuck when trying to come up with a word.

You remember the meaning of the word and you know it’s the appropriate time to use it, but it’s like the word is on the tip of your tongue .

How Does Language And Memory Develop?

You don’t only use your working memory when you’re doing math.

Working memory is also important for language use and development .

When you’re having a conversation with someone, you’re using your working memory to listen to what they’re saying, extract meaning from the words, store that meaning, and respond.

When someone talks to you, you have to remember what they’re saying and keep that information in your head long enough to act on it.

To do this, your brain doesn’t only listen to the words someone is speaking.

You also need to use your working memory to interpret the individual speech sounds you hear and turn them into words with meaning.

RELATED: Speech Therapy Treatments For Speech Sound Disorders

If your child struggles with their working memory, their language skills may also suffer as a result.

It may be more challenging for them to learn new speech and language skills because their brain can’t remember the things they’ve learned.

Even if they can remember what they’ve learned, it still may be hard for them to actively put that all together when speaking.

You may also notice that your child struggles with their attention skills or has poor behavior.

Helping your child to improve their memory can also help them speak more efficiently and confidently.

How Does Language And Memory Develop? | District Speech Therapy Services Speech Language Pathologist Therapist Clinic Washington DC

How Can Speech Therapy For Kids With Poor Memory Help?

Speech therapy can go a long way for poor memory, both for improving speech skills and simply for improving memory in general.

Your child’s speech therapist will engage your child in games and activities that help their memory with speech and language.

Storytelling games are often useful , as well as games like Broken Telephone or Simon Says, because they all require your child to use their memory.

Your child’s speech therapist will come up with a customized treatment plan for them, including games, to help them work on their memory and speech.

How Can Speech Therapy For Adults With Poor Memory Help?

Adults can also have trouble with their memory that may lead to speech issues.

Usually, this is memory loss that is acquired from something like a traumatic brain injury , degenerative disease , or stroke .

RELATED: How To Recognize When Somebody Is Having A Stroke

If you’ve experienced memory loss as an adult, there are usually a few different aspects of language you might struggle with.

Often, adults with memory loss struggle to understand grammar, word formation, and certain meanings of words.

If you’re an adult with poor memory, you may also struggle with the prosody of your speech, which refers to the rhythm of your speech.

Adults with memory loss can also experience anxiety , isolation, and loss of dignity.

Improving language skills is one way to help with some of these feelings.

If you are an adult with memory loss, your adult speech therapist will be able to create activities that stimulate the parts of your brain involved in speech and memory.

Your speech therapist can help you improve speech and communication skills to improve your quality of life.

Book Your Appointment With District Speech Today

Whether you have a child who struggles with their memory, or you’re an adult who has experienced memory loss, the feeling can be isolating.

Our qualified speech therapists can help improve your memory and aid in speech no matter your age.

Book your appointment with District Speech today .

District Speech and Language Therapy specializes in speech therapy, physical therapy, and occupational therapy solutions, for both children and adults, in the Washington D.C and the Arlington Virginia areas.

Symptoms - Aphasia

Aphasia affects everyone differently, but most people will have difficulty expressing themselves or understanding things they hear or read.

If aphasia has been caused by a sudden brain injury, such as a stroke or severe head injury , symptoms usually develop straight after the injury.

In cases where there's gradual damage to the brain as a result of a condition that gets worse over time, such as dementia or a brain tumour , the symptoms may develop gradually.

Expressive aphasia

Someone with expressive aphasia experiences difficulty communicating their thoughts, ideas and messages to others.

This may affect speech, writing, gestures or drawing, and causes problems with everyday tasks like using the telephone, writing an email, or speaking to family and friends.

People with expressive aphasia may have some of the following signs and symptoms:

slow and halting speech – with difficulty constructing a sentence
struggling to get certain words out – such as the names of objects, places or people
only using basic nouns and verbs – for example, "want drink" or "go town today"
spelling or grammatical errors
using a wrong but related word – such as saying "chair" instead of "table"
including nonsense words or their speech not making sense (speech-sound errors)

Receptive aphasia

A person with receptive aphasia experiences difficulty understanding things they hear or read. They may also have difficulty interpreting gestures, drawings, numbers and pictures.

This can affect everyday activities such as reading an email, managing finances, having conversations, listening to the radio, or following TV programmes.

People with receptive aphasia may have some of the following signs and symptoms:

difficulty understanding what people say
difficulty understanding written words
misinterpreting the meaning of words, gestures, pictures or drawings
giving responses that may not make sense if they've misunderstood questions or comments
not being aware of their difficulties with understanding, or their own speech errors

Aphasia symptoms associated with dementia

People with the most common types of dementia, such as Alzheimer's disease and vascular dementia , usually have a mild form of aphasia.

This often involves problems finding words and can affect names, even of people they know well.

It doesn't mean they don't recognise the person or don't know who they are, they just can't access the name or get mixed up.

Primary progressive aphasia

This is a rare type of dementia, where language is heavily affected. As it's a primary progressive condition, the symptoms get worse over time.

Usually, the first problem people with primary progressive aphasia (PPA) notice is difficulty finding the right word or remembering somebody's name.

The problems gradually get worse, and can include:

speech becoming hesitant and difficult, and making mistakes with the sounds of words or grammar
speech becoming slow with short, simple sentences
forgetting the meaning of complicated words, and later also simple ones, making it more difficult for them to understand other people
speech becoming more vague and the person having difficulty being specific or clarifying what they're saying
becoming less likely to join in with or start conversations

A person with PPA may also experience other symptoms later in their illness, including:

changes in their personality and behaviour
difficulties with memory and thinking – similar to Alzheimer's disease
difficulties with movement – similar to Parkinson's disease

Page last reviewed: 23 March 2021 Next review due: 23 March 2024

How Does Memory Affect Speech?

While speech and memory aren’t exactly directly related, children and adults with language or communication difficulties can also often struggle to recall certain information. This is especially true in cases where challenges with speech are a result of cognitive impairments. There are many strategies and exercises that can be used to help improve speech and memory, whether the speech and memory issues are related to a cognitive delay, a traumatic brain injury , or the result of a degenerative disease such as Alzheimer’s.

If you want to learn more about how speech and memory work together, schedule your free introductory call today with one of our highly specialized speech therapists.

What are Cognition and Memory?

Memory is the ability to recall or recount certain information in a timely manner. Many children who are affected by language or cognitive impairments struggle with the memory pieces that accompany the learning and mastering of new speech and language skills.

Cognition is the ability to think and analyze information. Cognitive impairments can also make it difficult for children to acquire and engage in new skills.

What are Word Retrieval and Recall?

Word retrieval is the ability to think of an appropriate or specific word at the moment that we need to. Everyone experiences getting stuck and being unable to think of a certain word despite knowing its meaning and having used it in the past. Some children with language disorders struggle with word retrieval due to disorganization within the language centers of the brain. Some children may have a very strong and expansive vocabulary but still struggle to retrieve the word they want during the conversation.

Recall is the ability to remember and recount a series of events logically and in the correct order to another person. This skill involves not only strong memory, speech, and language skills, but also the ability to plan and organize one’s thoughts.

What is Working Memory?

Working memory is the ability to hear something, understand and interpret it, and use that information to take action or complete a task. When we are given a simple math problem (“What’s 3 + 3?) We use our working memory to listen to the problem, interpret it, make our calculations and deliver our answer. Language abilities can be highly dependent on this skill set.

Language development and working memory work closely together and language skills depend significantly on working memory. When we are in conversation or watching a movie, we use working memory to listen to the words that are being spoken, interpret them and store the meaning or information we extract from them. This process occurs both at the sound and word levels. The sound level refers to the process of our brain decoding the sounds and translating those sounds into words. At the word level, our brain must take the words, decipher their meaning, and remember them long enough to complete whichever action is being asked of them.

In some cases, children who struggle with working memory can appear to struggle with attention or poor behavior. Efforts to improve their working memory can go a long way towards improving behavior as well as speech and language skills and lead which can ultimately lead to better academic success. Connect with one of our speech therapists to learn more about improving your working memory! Schedule your free introductory call today!

Do Speech Therapists Work on Memory? How Can Speech Therapy Help?

There are lots of fun and engaging games and activities that you can do with your child to promote their memory as it supports speech and language development. Speech therapists are dedicated to making sure that working with your child on memory skills will be fun and effective. Games and activities related to storytelling, Simon says and Broken Telephone can be excellent ways to exercise a child’s memory. Speech therapists create custom treatment plans that are completely unique to each of their client’s needs. Often speech therapists will also make suggestions to help the child compensate for deficiencies in working memory through the use of tools such as calendars, note-taking, engaging the other senses, and building routines.

Speech and language therapy has also been proven to be beneficial to adults struggling with memory loss due to a stroke, degenerative disease, or traumatic brain injury. Memory loss can deeply affect a person’s ability to function in their daily life. Often people experiencing memory loss experience feelings of isolation, anxiety, and feeling upset about a perceived loss of independence or dignity. Speech therapy can work to address memory and other cognitive deficits. Therapy can help to stimulate parts of the brain and aid in improving speech as well as improving information retention.

People who experience memory loss typically struggle with certain aspects of speech and language, such as struggling to understand certain meanings, as well as basic grammar and word-formation. They may also struggle with speech articulation as well as the fluidity and prosody of their speech. Speech therapists are experts at targeting these types of challenges as well as using memory to stimulate new growth and learning. Often family members are invited to join in therapy sessions, as familiar people can help to trigger past happy memories and positive emotions. Speech therapy has shown to not only improve speech and communication in Alzheimer’s patients but can also slow down the progression of the disease.

There is assistance available if you or someone you care about is having trouble speaking or communicating due to memory loss or impairments. Online speech therapy is an excellent resource that can benefit a wide variety of people who may be struggling with any number of challenges. You can meet with your highly specialized and qualified speech and language pathologist from the comfort of your own home. Start your journey towards improved memory and communication skills and schedule your free introductory call today!

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Monica Marzinske, CCC-SLP

Speech-language therapy.

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Speaking clearly: Help for people with speech and language disorders

Speech-Language

Speaking and language abilities vary from person to person. Some people can quickly articulate exactly what they are thinking or feeling, while others struggle being understood or finding the right words.

These struggles could be due to a speech or language disorder if communication struggles cause ongoing communication challenges and frustrations. Speech and language disorders are common.

It's estimated that 5% to 10% of people in the U.S. have a communication disorder. By the first grade, about 5% of U.S. children have a noticeable speech disorder. About 3 million U.S. adults struggle with stuttering and about 1 million U.S. adults have aphasia. These conditions make reading, speaking, writing and comprehending difficult.

People with speech and language disorders can find hope in rehabilitation. Speech-language pathologists can evaluate and treat these disorders. This can lead to a happier, healthier and more expressive life.

Types of speech and language disorders

Speech and language disorders come in many forms, each with its own characteristics:.

Aphasia People with aphasia have difficulty with reading, writing, speaking or understanding information they've heard. The intelligence of a person with aphasia is not affected.
Dysarthria People with dysarthria demonstrate slurred or imprecise speech patterns that can affect the understanding of speech.
Apraxia A person with this disorder has difficulty coordinating lip and tongue movements to produce understandable speech.
Dysphagia This condition refers to swallowing difficulties, including food sticking in the throat, coughing or choking while eating or drinking, and other difficulties.
Stuttering This speech disorder involves frequent and significant problems with normal fluency and flow of speech. People who stutter know what they want to say but have difficulty saying it.
Articulation disorder People with this disorder have trouble learning how to make specific sounds. They may substitute sounds, such as saying "fum" instead of "thumb".
Phonological disorder Phonological processes are patterns of errors children use to simplify language as they learn to speak. A phonological disorder may be present if these errors persist beyond the age when most other children stop using them. An example is saying "duh" instead of "duck."
Voice Voice disorders include vocal cord paralysis, vocal abuse and vocal nodules, which could result in vocal hoarseness, changes in vocal volume and vocal fatigue.
Cognitive communication impairment People with cognitive communication impairment have difficulty with concentration, memory, problem-solving, and completion of tasks for daily and medical needs.

Speech and language disorders are more common in children. It can take time to develop the ability to speak and communicate clearly. Some children struggle with finding the right word or getting their jaws, lips or tongues in the correct positions to make the right sounds.

In adults, speech and language disorders often are the result of a medical condition or injury. The most common of these conditions or injuries are a stroke, brain tumor, brain injury, cancer, Parkinson's disease, multiple sclerosis, Lou Gehrig's disease or other underlying health complications.

Treatment options

Speech and language disorders can be concerning, but speech-language pathologists can work with patients to evaluate and treat these conditions. Each treatment plan is specifically tailored to the patient.

Treatment plans can address difficulties with:

Speech sounds, fluency or voice
Understanding language
Sharing thoughts, ideas and feelings
Organizing thoughts, paying attention, remembering, planning or problem-solving
Feeding and swallowing
Vocabulary or improper grammar use

Treatment typically includes training to compensate for deficiencies; patient and family education; at-home exercises; or neurological rehabilitation to address impairments due to medical conditions, illnesses or injury.

Treatment options are extensive and not limited by age. Children and adults can experience the benefits of treatment.

If you or a loved one are struggling with speech and language issues, you are not alone. Millions of people experience similar daily challenges. Better yet, help is available.

Monica Marzinske is a speech-language pathologist in New Prague , Minnesota.

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8 Surprising Signs You Could Be at Higher Risk for Memory Problems

The health of your gut, eyes, mouth and more can affect the health of your brain.

Rachel Nania,

collage of an eye exam, french fries and dental floss

As researchers learn more about the aging brain, one thing is clear: brain health is not just a neck-up problem.

“What’s becoming better appreciated is that the risk of developing brain diseases is linked to the health of the [other] organs,” says Constantino Iadecola, M.D., a neurologist and chair of the Feil Family Brain and Mind Research Institute at Weill Cornell Medicine. “The whole story is not the brain.”

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Indeed, the health of your heart, gut, eyes — even your mouth — can impact your brain and may affect your risk for developing thinking and memory problems as you age.

Here are eight warning signs that you could be at higher than average risk for cognitive issues, according to the latest research.

1. You snore

If you snore a lot — or your partner tells you that you do — it might be time to get it checked out. Snoring, gasping and snorting during sleep can be warning signs of sleep apnea, a condition where people intermittently stop and restart breathing during sleep. When left untreated, sleep apnea has been linked to increased dementia risks.

Evidence is mounting. A preliminary study released March 3 by the American Academy of Neurology found that people who reported sleep apnea symptoms were about 50 percent more likely to also report having memory or thinking problems compared to people who did not have sleep apnea symptoms.

“During those [nonbreathing] phases of apnea, your brain doesn’t get enough oxygen,” Iadecola says. “Day in and day out, the brain is going to pay a toll for it.”

According to AARP’s Global Council on Brain Health, “proper treatment of sleep apnea can improve sleep at night , reduce daytime sleepiness, serve to improve cognition and slow cognitive decline.” A CPAP (continuous positive airway pressure) machine is the most common treatment for sleep apnea.

2. You don’t floss

Taking care of your teeth is important for a pretty smile — but that’s not all. Researchers have uncovered a link between oral health and brain health.

A study published in July 2023 in the journal Neurology found that gum disease and tooth loss were linked to brain shrinkage in the area of the brain that plays a role in memory, known as the hippocampus. And previous research led by scientists at the National Institutes on Aging and published in the Journal of Alzheimer’s Disease found that older adults with signs of gum disease and mouth infections were more likely to develop Alzheimer’s disease.

A 2022 analysis of 47 studies reached a similar conclusion: Poor periodontal health was associated with both cognitive decline and dementia.

A possible explanation for this association is chronic inflammation caused by bacteria in the mouth, which can travel through the bloodstream and into the brain. Inflammation is thought to play a role in the development and progression of dementia.

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3. You eat a lot of junk food

Ultra-processed foods — packaged snacks , frozen dinners and fast-food favorites — may be tasty, but research suggests they aren’t doing your brain any favors. A study that appeared in the February 2023 issue of JAMA Neurology found that people who took in a higher share of calories from ultra-processed foods were more likely to experience cognitive decline.

Similarly, a 2022 study from the journal Neurology found that when people increased the amount of ultra-processed foods they consumed, their risk for dementia went up. However, when the junk food was replaced by unprocessed or minimally processed foods , their risk for dementia decreased.

“Ultra-processed foods are meant to be convenient and tasty, but they diminish the quality of a person’s diet,” study author Huiping Li said in a statement. “These foods may also contain food additives or molecules from packaging or produced during heating, all of which have been shown in other studies to have negative effects on thinking and memory skills.”

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4. You’re having trouble hearing

If you’ve noticed it’s getting harder to hear, it’s time to make an appointment with a health care provider. Researchers from Johns Hopkins Bloomberg School of Public Health found in a 2023 JAMA study that moderate to severe hearing loss was associated with a higher prevalence of dementia among a nationally representative sample of older adults in the U.S. Hearing aid use, however, was associated with lower dementia prevalence.

Previous studies have reached similar conclusions. NIH-funded research, published in 2023 in The Lancet, found that hearing aids reduced the rate of cognitive decline in older adults who are at high risk for developing dementia by almost 50 percent over a three-year period.

You use the brain to process what you hear, says Douglas Scharre, M.D., professor of clinical neurology and psychiatry at The Ohio State University Wexner Medical Center. So when there’s hearing loss, “you’re going to reduce your stimulation to the brain,” he says.

Another factor that can affect brain health is the social isolation that often accompanies hearing loss. People who have a hard time hearing tend to pull away from conversations and social interactions. The Centers for Disease Control and Prevention (CDC) notes that social isolation in older adults is associated with a roughly 50 percent increased risk of dementia.

“ Hearing loss is very treatable in later life, which makes it an important public health target to reduce risk of cognitive decline and dementia,” hearing expert Frank Lin, M.D., a researcher on both of the above studies, said in a statement. “Until we know more, we recommend for general health and well-being that older adults have their hearing checked regularly and any hearing issues properly addressed.”

5. You are skipping your workouts

Yet another reason to get up and move your body: Multiple studies have found that regular exercise may slash your risk of memory loss. For example, a 2022 meta-analysis published in the journal Neurology found that study participants who participated in physical activities — biking, walking, running, swimming, yoga, dancing and more — had a 17 percent lower risk of dementia than physically inactive participants.

Another study, published in JAMA Neurology , found an association between walking and dementia risk. Older adults who got in just under 10,000 steps a day — 9,800 — were 50 percent less likely to develop dementia. And most recently, a 2024 study in the Journal of Alzheimer’s Disease found that adults who exercised had bigger brains than those who didn’t.

“Physical exercise is a great brain activity,” Scharre says.

No need to start training for a marathon: Research suggests even light physical activity has brain benefits. And don’t forget about strength and balance exercises — these are especially important for older adults who are at higher risk for falling . According to the CDC, falls are the most common cause of TBI, or traumatic brain injury , which can affect thinking and memory skills and can increase the risk of developing dementia.

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6. You missed your last eye exam

Around 100,000 cases of dementia may have been prevented if vision problems were corrected, a study published in JAMA Neurology found. The authors of the 2022 study, funded by the National Institute on Aging (NIA), also note that about 80 percent of vision problems occur in adults 50 years and older, and 90 percent of cases are preventable or can be treated.

Like hearing loss, vision loss can result in a reduction in brain stimulation and social isolation, researchers say. People over 60 should get an eye exam every year or two, according to the NIA.

7. You’re not regular

Constipation is not uncommon, especially among older adults. But new research suggests that being backed up may not be good for the brain.

A study presented at the 2023 Alzheimer’s Association International Conference linked less frequent bowel movements with worsening cognitive function . Researchers found that compared to people who had daily bowel movements, people who were constipated (had bowel movements every three days or longer) had brains that aged the equivalent of three years faster.

This adds to other research linking gut health to brain health. A large observational study published in the journal Gut found that people with inflammatory bowel disease were more than twice as likely to develop dementia than those without it.

The gut-brain connection is an area that scientists are actively studying. In the meantime, experts say if you’re experiencing irregularity, talk to your doctor about fixing the issue — it could be as simple as an adjustment to your diet or medications. What’s more, fermented foods and foods that are high in fiber — fruits, vegetables, legumes and grains — can help to build a healthy gut , the Mayo Clinic says.

8. You don’t get enough sleep

Mounting evidence shows just how important sleep is for the brain. Recently, a study published in December 2023 in JAMA Network Open found that adults who sleep less than 7 hours a night had a significantly higher risk of cognitive impairment, which can include difficulties thinking, remembering and making decisions. An earlier study, published in 2022, from researchers at Harvard Medical School, found that older adults who slept less than 5 hours a night were twice as likely to develop dementia than those who got 6 to 8 hours of sleep each night.

Some evidence suggests that a “housekeeping” process could explain the link between lack of sleep and worsening memory. During sleep, toxins get flushed from the brain, including beta-amyloid, which is a protein in the brain associated with Alzheimer’s disease . “It could be that by limiting the time the brain has got to get rid of waste, you may end up [accumulating] things you don’t want in your brain,” Iadecola says.

Rachel Nania is an award-winning health editor and writer at AARP.org, who covers a range of topics including diseases and treatments.

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“Long COVID”: COVID-19’s lasting effects on speech, language, and cognitive function

We’ve heard from more and more COVID-19 survivors that the virus’ impact lasts beyond the first few weeks of immediate symptoms. For some patients, COVID-19 has a long-term, far-reaching impact on their daily lives, impacting them physically, emotionally, and cognitively. This is especially true for many people with previously diagnosed conditions, such as prior strokes, TBIs, or diagnoses of dementia. Read on to hear current research findings related to COVID-19’s lasting effects on cognitive function, and what we here at Constant Therapy Health are doing about it.

Long COVID: The latest challenge in the fight against the novel coronavirus

As we continue to learn more about COVID-19, a new term, “Long COVID”, emerged. So what IS Long COVID? What does the existing research tell us? When we analyze an illness like COVID-19 we look at mortality, or how deadly it is, as well as morbidity, or the overarching impact of the disease other than death. Research thus far mostly prioritized the mortality of COVID-19 (understandably so given the urgency to better understand this deadly virus). However, more and more research is emerging assessing the morbidity of COVID-19 and its long-term symptoms. Long COVID can cause a variety of symptoms. They range from more physical symptoms such as pulmonary, cardiovascular, and systematic issues like fatigue, to neuropsychological symptoms impacting cognition, speech and language, memory, emotion and mood, and the now hallmark symptoms of loss of smell and taste. As the scientific community continues to uncover the lasting symptoms associated with Long COVID, we also need to make a plan to figure out how to best help those currently struggling with these long-term effects.

How COVID-19 impacts speech, language, and cognition

There are four ways that COVID-19 is currently impacting speech, language, and cognitive skills:

Neuropsychological impact of COVID-19

As noted above, Long COVID is receiving more and more attention as scientists prioritize investigating the long term effects of the disease.

In a not-yet peer reviewed paper analyzing survey data from over 3,700 people who had symptoms consistent with COVID-19, researchers found trends not only in the types of symptoms that people had, but also in the timing at which they experienced them:

Delayed onset : These symptoms ranged from physical symptoms such as fatigue, dry cough, or nausea, to more neuropsychological symptoms such as short-term memory loss, problem solving, and speech and language issues. Interestingly, researchers found that speech, language, and cognitive issues tended to emerge 4-8 weeks after initial COVID-19 symptoms, and persisted beyond 24 weeks.
Life-altering : The same study found that due to Long COVID many people were unable to return to work, emphasizing the profound impact of these issues, and the importance of figuring out how to help these patients.
I mpacts cognition, speech, and language : This study found that the most common issues were short-term memory loss, long-term memory loss, and cognitive dysfunction including difficulty with attention, thinking, executive functioning, problem solving, and slowed thoughts. In fact, 85.1% of all respondents reported experiencing brain fog and cognitive dysfunction. Speech and language issues occurred in 48.6% of respondents. The most common speech and language issue was word finding. (Image from: Davis, et. al 2020)

In another single-center study looking at persistent symptoms following COVID-19 hospitalization, scientists found that even after over 100 days, patients still reported fatigue (55%), shortness of breath (42%), loss of memory (34%), concentration difficulties (28%), and sleep disorders (30.8%).

Mental health impact of COVID-19

Battling COVID-19 also brings mental health challenges, which can impact functional presentation and lower treatment engagement.

Take a holistic approach to therapy options : This study emphasizes that patients recovering from neurological sequelae of COVID should be carefully monitored. This vigilance is required because COVID’s independent impacts on brain function, which we don’t yet fully understand, may also compound with recovery from neurological conditions such as strokes. The authors recommend early conversations about needs following acute care, such as psychotherapy, cognitive reevaluations, and vocational counseling.

Do to the highly contagious nature of the virus, social isolation is a pervasive requirement for managing the spread of COVID-19. Patients with pre-existing conditions such as dementia, aphasia, traumatic brain injuries, and other neurological disorders are particularly vulnerable to the impacts of isolation. Without frequent social interaction, patients do not get to apply and practice their speech, language, and cognitive skills as readily, which can lead to a decline in each of these areas of need. While these patients are careful to isolate to stay safe from the virus itself, studies show that the isolation of COVID-19 results in a deterioration of emotional state and communication skills of these patients.

Social isolation is a risk factor : The importance of continued therapy access even when social distancing during COVID-19 is further reinforced in this article , which reminds us that community activities are critical for patients with aphasia, and in fact social isolation is a risk factor for stroke, dementia, or heart disease. The author encourages use of telepractice and telecommunication tools to provide social connections, and also to receive speech and language therapy services.
Therapy is a protective factor : The authors of this study encourage therapy to continue via tele-therapy when possible, and that patients should focus on rehabilitation programs that allow them to keep training their communication skills to avoid further deterioration if they are no longer participating in therapy.

So, what do we do about it?

These long-term and comorbid effects of COVID-19 are all still very new issues, but due to their persistent, wise-reaching impact on people’s ability to participate in their daily lives and successfully return to work, continuing to educate ourselves is of the utmost importance. The social and economic impacts of Long COVID need to be addressed expediently.

“Although COVID-19 is novel, the cognitive and linguistic symptoms SLPs will observe in survivors are not novel.”

Amy Ramage rightfully called upon speech-language pathologists to look at how we can help these patients given the applicability of speech-language pathology approaches to evaluation and intervention for similar populations of critical care patients. Whether the cause is a direct result of COVID-19 attacking patients’ neurological centers, or other neurological consequences of COVID-19 like stroke or intermittent hypoxia, we need to be prepared to help these patients. As Ramage aptly puts it, “although COVID-19 is novel, the cognitive and linguistic symptoms SLPs will observe in survivors are not novel.” We need to use objective and subjective evaluations to assess cognitive, linguistic, and social communication systems. We should treat all deficits with an interprofessional approach, and per Ramage’s article, treatment should not stop when patients are discharged but should continue when patients are at-home as well.

The research community hasn’t yet been able to study whether rehabilitation helps combat COVID-19 language and cognitive symptoms. However, that’s exactly what we’d like to find out. Constant Therapy has the therapy activities to address the language and cognitive symptoms associated with Long COVID and the neurological sequelae of COVID-19 – now it’s a matter of figuring out whether our therapy activities can help these specific patients.

We look forward to doing our part in the research community to help determine how we can best assist patients with long-term cognitive and language impairments resulting from the COVID-19 pandemic.

Davis, H., Assaf, G., McCorkell, L., Wei, H., Low, R., Re’em, Y., Redfield, S., Austin, J., & Akrami, A. (2020). medRxiv . https://doi.org/10.1101/2020.12.24.20248802
Unnithan, A. (2020). A brief review of the neurological manifestations of the coronavirus disease. Egyption Journal of Neurological Psychiatry and Neurosurgery . doi: 10.1186/s41983-020-00244-6
Arenivas, A., Carter, K., Harik, L., & Hays, K. (2020). COVID-19 neuropsychological factors and considerations within the acute physical medicine and rehabilitation setting. Brain Injury . https://doi.org/10.1080/02699052.2020.1786603
Lu, Y., Li, X., Geng, D., Mei, N., Wu, P., Huang, C., Jia, T., Zhao, Y., Wang, D., X., A, & Yin, B. (2020). Cerebral micro-structural changes in COVID019 patients – An MRI-based 3-month follow-up study. EClinicalMedicine . https://doi.org/10.1016/j.eclinm.2020.100484 .
Garrigues, E., Janvier, P., Kherabi, Y., Le Bot, A., Hamon, A., Gouze, H., Doucet, L., Berkani, S., Oliosi, E., Mallart, E., Corre, F., Zarrouk, V., Moyer, J., Galy, A., Honsel, V., Fantin, B., & Nguyen, Y. (2020). Letter to the Editor: Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19. Journal of Infection . https://doi.org/10.1016/j.jinf.2020.08.029
Ramage, A. (2020). Potential for cognitive communication impairment in COVID-19 survivors: A call to action for speech-language pathologists. American Journal of Speech Language Pathology. https://doi.org/10.1044/2020_AJSLP-20-00147
Wilson, B., Betteridge, S., & Fish, J. (2020) Neuropsychological consequences of COVID-19. Neuropsychological Rehabilitation, 30:9, 1625-1628. https://doi.org/10.1080/09602011.2020.1808483
Pisano, F., Giachero, A., Rugiero, C., Calati, M., & Marangolo, P. Does COVID-19 impact less on post-stroke aphasia? This is not the case. Frontiers in Psychology . https://doi.org/10.3389/fpsyg.2020.564717
Kong, A. (2021). The impact of COVID-19 on speakers with aphasia: What is currently known and missing? Journal of Speech Language and Haring Research. https://doi.org/10.1044/2020_JSLHR-20-00371

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May 18, 2022

What do memory, processing and retention problems look like?

In a classroom setting, pupils with memory and processing difficulties tend to stick out to teachers.

Students with processing difficulties tend to be in the lower ability groups and are likely to be performing below age-related expectations. Students can struggle to keep up with input teaching and follow spoken or written instructions. There may be challenges with learning new vocabulary or new topics or languages. Some children can find it hard to maintain social relationships and friendships.

‘Memory’ refers to our ability to hold, process and recall information that we have been given. For pupils who have difficulties with this skillset, this will be evident in their ability to respond to longer instructions or answer questions based on the teaching input you’ve just given.

How do memory difficulties impact on learning?

Children need memory and processing skills to underpin their learning in all aspects of the curriculum. Let’s look more closely at where memory and processing difficulties may impact on learning:

Over 80% of children with poor working memory struggle in reading and maths.

Skills such as counting sequences, times tables and number bonds all require a level of ability to remember, rehearse and repeat these set, familiar sequences.

Children in younger age groups (early years and key stage 1) may struggle with remembering the days of the week, months of the year and their own birthdays.

Older children (i.e. key stage 2 upwards) are likely to find more complex equations and formulae tricky.

Memory and processing skills impact on reading comprehension, including understanding the text, being able to relate their own lives to the information, draw inferences and re-tell the information to another person.

Phonics skills such as sounding out words when writing or recalling spelling patterns can be impacted which will affect pupils from key stage 1 upwards. Remembering grammatical features such as irregular verbs and tenses may also be affected.

Reading comprehension tasks will be challenging and students will find it hard to recall parts or most of what they have just read. Answering specific questions on the text will be very tricky without the student applying strategies to help them visualise, relate and recall.

For all age groups, remembering and following precise instructions can be a challenge and strategies to support pupils with this will be the key to a successful experiment.

Students may also find it difficult to learn categories such as animal families, forces, textures and types of rock. Older pupils can find the learning and remembering of formulas and elemental properties a challenge.

Wider Curriculum

Key dates, important historical facts and key information about eras will be incredibly hard for some children with memory and processing difficulties to recall without targeted interventions and teaching.

In Geography, learning about countries and continents, planets and space, species and demographics could prove a challenge for pupils with processing difficulties.

Learning about different religions, cultural norms and religious festivals all require good memory and processing skills.

Meeting Age Related Expectations

Children with memory and processing difficulties are likely to make poor academic progress without support from high quality teaching, reasonable adjustments in class and targeted interventions where necessary.

These children often fall below the criteria for SEN and are not always flagged up to Inclusion or SEN support in school, let alone for assessment by outside professionals like Speech and Language Therapy or Educational Psychology.

How can we help our students with these problems?

A combined approach of strategies and interventions can help.

First, adults working with children who have memory and processing difficulties should be aware of and use a range of strategies to support them.

Secondly, the students can be shown a number of strategies to use by themselves and which they can self-refer or prompt when they are needing to remember and recall information they are learning.

Lastly, there are lots of interventions, activities and games which can be played with children of all ages and key stages which can boost their memory and processing skills which in turn will have a positive impact on academic progress and achievement.

What does this help look like?

Teachers need help and training to boost their skills in identifying and supporting the needs of pupils with memory, processing and retention difficulties. They, along with Learning Support Staff need to have a selection of impactful, fun and effective interventions and games to help develop the missing skills and improve the learning experience for the pupils.

In my Supporting Children with Memory and Processing Difficulties course, you’ll find the information, tips and strategies you need to help children and young people of any age to improve their memory, processing and retention skills.

You’ll also find lots of video demonstrations of activities to use in 1:1, small group or even whole class in interventions.

In addition to this, there are multiple documents that you can download, including the Memory and Processing Interventions eBook which contains a selection of games which can be adjusted to meet the age, ability, interests and motivations of the pupil(s) you work with.

The course is mostly video-based with around 75 minutes of total video time, but allow some extra time for your own reflections. It's available instantly, with no waiting for start dates or deadlines and there's no written 'homework' for you to do. As it's all pre-recorded, you can stop and start as much as you like, completing it at your own pace.

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v.4(6); 2011 Nov

The cognitive impact of antiepileptic drugs

Effective treatment of epilepsy depends on medication compliance across a lifetime, and studies indicate that drug tolerability is a significant limiting factor in medication maintenance. Available antiepileptic drugs (AEDs) have the potential to exert detrimental effects on cognitive function and therefore compromise patient wellbeing. On the other hand, some agents may serve to enhance cognitive function. In this review paper, we highlight the range of effects on cognition linked to a variety of newer and older AEDs, encompassing key alterations in both specific executive abilities and broader neuropsychological functions. Importantly, the data reviewed suggest that the effects exerted by an AED could vary depending on both patient characteristics and drug-related variables. However, there are considerable difficulties in evaluating the available evidence. Many studies have failed to investigate the influence of patient and treatment variables on cognitive functioning. Other difficulties include variation across studies in relation to design, treatment group and assessment tools, poor reporting of methodology and poor specification of the cognitive abilities assessed. Focused and rigorous experimental designs including a range of cognitive measures assessing more precisely defined abilities are needed to fill the gaps in our knowledge and follow up reported patterns in the literature. Longitudinal studies are needed to improve our understanding of the influence of factors such as age, tolerance and the stability of cognitive effects. Future trials comparing the effects of commonly prescribed agents across patient subgroups will offer critical insight into the role of patient characteristics in determining the cognitive impact of particular AEDs.

Introduction

The incidence of adverse effects is an important issue when prescribing antiepileptic drugs (AEDs), as some of the most effective medications for seizures are associated with a considerable degree of toxicity. Studies indicate that drug tolerability is a significant limiting factor in treatment maintenance, and drug retention rates are often determined by side-effect profiles [ Bootsma et al . 2009 ; Chung et al . 2007 ]. Older AEDs may still be prescribed, owing to advantages such as lower cost, wide availability and long-term experience, but often exhibit greater toxicity than newer drugs. Recently developed agents tend to differ in terms of mechanism of action and pharmacokinetic properties, and are often better tolerated than older drugs. However, all AEDs have the potential to exert detrimental effects on cognitive function. A thorough appreciation of the negative cognitive effects linked to a variety of AEDs makes a crucial contribution to therapeutic success.

There are currently more than 20 different agents which are licensed for use in treating seizures in the UK. These include phenobarbital and phenytoin, which were popular until the 1950s. Over the next couple of decades, sodium valproate and carbamazepine were developed. These drugs, in addition to primidone and ethosuximide, were the six agents of choice until the 1990s, when a newer generation of drugs became available. These include tiagabine, pregabalin, gabapentin, topiramate, clobazam, oxcarbazepine, lamotrigine and levetiracetam.

In terms of adverse cognitive effects the vulnerabilities of the individuals treated need to be carefully considered. Differing metabolic profiles in children, the elderly or the acutely unwell may lead to an increased chance of toxicity, and a further consideration is interactions with other medications the patient may be taking. Patients with existing cognitive problems may comprise one population at greater risk of the influence of agents with adverse cognitive effects.

Epilepsy can impair an individual’s functioning within work and educational domains [ Bishop and Allen, 2003 ]. As well as adverse cognitive effects, some AEDs may have the advantage of improving cognitive performance. Such beneficial influences may simply occur as a result of seizure control, or in association with positive effects on mood or psychiatric profile. However, a number of agents may demonstrate efficacy in enhancing cognitive function in a more direct way, by improving alertness or cognitive capacity.

In this review of current literature, we highlight the range of effects on cognition linked to a variety of newer and older agents used to control seizures. These include key alterations in both executive and broader neuropsychological functions, which can exert a critical influence on patients’ quality of life and wellbeing. Because drug side-effect profiles are often related to patient characteristics, this review is followed by a critical discussion, which will offer recommendations for prescribing both in general and in relation to more specific clinical cases. Finally, we evaluate reviewed studies in terms of methodological limitations, providing essential guidance for insightful further research.

Relevant studies were identified through searches of PubMed and ISI Web of Knowledge (1980–2011). PubMed was searched for articles containing ‘epilepsy’ and ‘cogniti*’ in the abstract/title, and ‘drug name’ (phenobarbital, primidone, phenytoin, carbamazepine, valpro*, ethosuximide, tiagabine, vigabatrin, clobazam, zonisamide, gabapentin, pregabalin, topiramate, lamotrigine, oxcarbazepine, levetiracetam) in the title. For the ISI search, we used ‘epilepsy’ and ‘cogniti*’ as topic, and the drug name as title. Only original studies on patients with epilepsy that were written in English were included. We excluded case studies, letters and editorials from our search. We also searched the reference lists of articles identified using this search strategy to increase the number of relevant randomized, blinded, controlled studies. Studies which failed to report findings related to cognitive effects were excluded.

Antiepileptic drugs and cognition

Phenobarbital and primidone.

Some studies report few cognitive adverse effects (CAEs) with the use of phenobarbital [ Wang et al . 2006 ]. However, studies involving children with epilepsy have linked this agent to lower IQ [ Farwell et al . 1990 ; Camfield et al . 1979 ], and discontinuation of the drug can improve total IQ (mainly affecting nonverbal items) in children [ Tonekaboni et al . 2006 ]. Phenobarbital is considered to have worse cognitive effects than valproate or carbamazepine [ Calandre et al . 1990 ; Vining et al . 1987 ]. When compared with carbamazepine, primidone has been found to cause more adverse effects on motor performance and attention/concentration tests [ Smith et al . 1987 ; Rodin et al . 1976 ]. One study reported attentional and memory difficulties in children [ Riva and Devoti, 1996 ], but these effects were reversible after discontinuation. Another study [ Manni et al . 1993 ] showed that when compared with controls, patients taking phenobarbital showed longer movement times, impaired attention and reduced processing speed, but no relationship was found with drug concentration.

Phenytoin has been implicated in declines in concentration, memory, visuomotor functions and mental speed [ Pulliainen and Jokelainen, 1995 ; Gillham et al . 1990 ; Andrewes et al . 1986 ]. These effects may be dose related [ Gillham et al . 1990 ], although one study reported no such relationship for cognitive-motor performance [ Aman et al . 1994 ]. Another study reported slowed performance on information processing tasks with phenytoin in comparison with carbamazepine, but no differences for memory or selective attention [ Aldenkamp et al . 1994 ]. Some studies report more detrimental effects on memory than carbamazepine [ Pulliainen and Jokelainen, 1995 ; Andrewes et al . 1986 ], although the opposite pattern has been seen in children [ Forsythe et al . 1991 ]. A double-blind placebo-controlled study indicated attention and motor performance may improve after withdrawal [ Duncan et al . 1990 ], and similar improvements in concentration and psychomotor performance were noted in another controlled study [ May et al . 1992 ].

Despite reported CAEs, Pulliainen and Jokelainen concluded that the long-term effects of phenytoin on cognition are relatively few and restricted mainly to some visually guided motor functions [ Pulliainen and Jokelainen, 1995 ]. More favourable findings include minimal cognitive effects in children [ Forsythe et al . 1991 ] and elderly patients [ Craig and Tallis, 1994 ], improvements in Stroop performance in partial epilepsy [ Bittencourt et al . 1993 ], no differences on tasks assessing verbal and performance intelligence, memory and visuomotor function, before and after treatment in drug-naïve adult patients [ Sudhir et al . 1995 ] and a similar cognitive profile to oxcarbazepine [ Aikiä et al . 1992 ].

Carbamazepine

A number of cognitive and psychomotor effects have been linked to carbamazepine [ Gillham et al . 1988 ]. A double-blind trial reported deterioration in measures of information processing speed and attention [ Wesnes et al . 2009 ]. Other studies report poorer verbal fluency in adults with partial seizures than in control subjects [ Aikiä et al . 2006 ], detrimental effects on memory [ Shehata et al . 2009 ; Forsythe et al . 1991 ], worse arithmetic performance [ Kang et al . 2007 ] and faster motor skills after discontinuation [ Duncan et al . 1990 ]. Impaired movement time, reaction time, finger tapping rate and number cancellation were seen in one study, but these effects remitted by 1 month after treatment commencement [ Larkin et al . 1992 ].

A randomized, double-blind, placebo-controlled study [ Hessen et al . 2006 ] involving 150 epilepsy patients on AED monotherapy (mainly carbamazepine or valproate) found that drug discontinuation significantly improved performance in tests that required complex cognitive processing under time pressure, but not in more simple tasks of attention and reaction time. A later study reported similar findings, whereby performance improved in a verbal fluency task, a Stroop task, a language task and a reaction time task after discontinuation of carbamazepine [ Hessen et al . 2009 ].

In relation to other AEDs, it has been suggested that carbamazepine has a cognitive profile that is worse than levetiracetam [ Lee et al . 2011 ] and lamotrigine [ Gillham et al . 2000 ] but better than phenytoin [ Pulliainen and Jokelainen, 1994 ; Andrewes et al . 1986 ]. Forsythe and colleagues reported that carbamazepine-treated children performed worse than valproate-treated children on memory tasks [ Forsythe et al . 1991 ]. However, another study [ Coenen et al . 1995 ] reported that the cognitive profiles of valproate and carbamazepine were similar except for some aspects of attention and memory, in which individuals taking valproate scored better, and for some motor tests, in which individuals taking carbamazepine performed faster. These effects appear mild when compared with those of phenytoin and phenobarbital.

Detrimental effects on cognition are unlikely to be widespread. One study reported significantly worse performance on the Digit Symbol Substitution Test (DSST), but no difference for tracking tasks and visual analogue scales [ Pieters et al . 2003 ]. Another study of patients with partial epilepsy showed no impairments in selective attention, memory or executive functions compared with controls, although slower information processing speed was seen with monotherapy [ Engelberts et al . 2002 ]. Despite no decline in coordination, memory, concentration or mental flexibility, a lack of practice effects on tasks appeared to suggest subtle changes in cognitive function in one study [ Prevey et al . 1996 ]. Similar findings were reported by Pulliainen and Jokelainen [ Pulliainen and Jokelainen, 1994 ]. Another report indicated that for children with partial epilepsy, carbamazepine did not have significant negative effects on memory and attention tasks, although performance improved slightly after withdrawal [ Riva and Devoti, 1999 ]. Other studies report little evidence of CAEs [ Donati et al . 2007 ; Sudhir et al . 1995 ].

Some positive effects on cognition have been reported, consisting mainly of improvements in memory. For example, one study showed that story recall improved in children with benign rolandic epilepsy when treated with carbamazepine [ Seidel and Mitchell, 1999 ]. Other beneficial effects on memory include improved immediate memory and late recall [ Bittencourt et al . 1993 ] and better retrieval from episodic and semantic memory in adults and adolescents [ Kälviäinen et al . 1995 ]. There may be a mild beneficial effect on hand–eye coordination in children with complex partial epilepsy in addition to improvements in memory [ O’Dougherty et al . 1987 ]. Memory and visual information processing may benefit most from the use of controlled-release medication [ Aldenkamp et al . 1987 ]. Despite these encouraging findings, some studies suggest carbamazepine is more likely to lead to cognitive deterioration than improvement [ Helmstaedter and Witt, 2010 ]. Factors that may be related to a greater incidence of cognitive effects include higher dose [ Gillham et al . 1988 ; O’Dougherty et al . 1987 ], longer duration of intake [ Shehata et al . 2009 ] and polytherapy [ Gillham et al . 1988 ].

Sodium valproate and ethosuximide

Studies are listed in Table 1 . A number of studies have indicated that valproate exerts little detrimental impact on cognitive function [ Sun et al . 2008 ; Donati et al . 2007 ; McKee et al . 1992 ; Gillham et al . 1991 ]. However, a small minority of patients (5 of 364 adults in one study) can develop parkinsonism with associated memory problems and psychomotor slowing [ Ristic et al . 2006 ]. One study reported no decline in tasks assessing coordination, memory, concentration or mental flexibility, although no practice effects were seen that were evident in controls, perhaps indicating very subtle changes in cognitive function [ Prevey et al . 1996 ]. Minor changes in cognitive function have been reported in elderly patients [ Craig and Tallis, 1994 ], adults [ Spitz and Deasy, 1991 ] and children [ Stores et al . 1992 ]. However, in the latter study, modest adverse cognitive effects were seen early in treatment, which could have been the result of seizure discharge. Another study showed no relationship between plasma concentration and cognitive performance in children [ Brouwer et al . 1992 ]. One double-blind, placebo-controlled study reported more convincing evidence of improved motor skills after discontinuation [ Duncan et al . 1990 ]. Fortunately, the CAEs associated with valproate are likely to be reversible [ Galassi et al . 1990 ].

Studies on the cognitive effects of valproate in patients with epilepsy.

AEDs, antiepileptic drugs; CAEs, cognitive adverse effects; CBZ, carbamazepine; cont, controlled; DB, double-blind; ETX, ethosuximide; GBP, gabapentin; HCs, healthy controls; LTG, lamotrigine; OL, open-label; OXC, oxcarbazepine; PC, placebo-controlled; PHB, phenobarbital; PHT, phenytoin; rand, randomized; retro, retrospective; SB, single-blind; TPM, topiramate; VGB, vigabatrin; VPA, sodium valproate.

In relation to the effects of other AEDs on cognitive function, valproate has been suggested to be preferable to carbamazepine [ Forsythe et al . 1991 ], phenobarbital [ Vining et al . 1987 ] and topiramate [ Sun et al . 2008 ; De Araujo Filhou 2006 ; Meador et al . 2003 ]. However, a recent study by Glauser and colleagues reported that attentional dysfunction was more common with valproic acid than ethosuximide (in 49% of the children compared with 33%) [ Glauser et al . 2010 ]. In another study [ Capovilla et al . 1999 ] ethosuximide led to no side effects in nine patients with partial epilepsy, and improvements in cognitive performance with the use of ethosuximide have been reported for individuals both with and without epilepsy [ Browne et al . 1975 ]. Ethosuximide may therefore prove a more favourable option than valproate.

A few CAEs have been reported with the use of tiagabine, such as deterioration in verbal memory from 3 months after baseline tests [ Fritz et al . 2005 ]. However, some studies, including double-blind, placebo-controlled trials, have reported no negative impact on cognition [ Aikiä et al . 2006 ; Dodrill et al . 1997 ; Kälviäinen et al . 1996 ; Sveinbjornsdottir et al . 1994 ]. It appears that most reports indicate potential for positive influences, such as improved motor speed, concentration, and verbal fluency after use [ Dodrill et al . 1998 ]. An add-on study in adults with partial seizures documented similar effects on verbal fluency in addition to faster perceptual/motor speed for tiagabine in comparison with carbamazepine [ Dodrill et al . 2000 ]. Patient-perceived cognition has also been shown to improve soon after treatment commencement [ Cramer et al . 2001 ].

Vigabatrin has demonstrated few CAEs when compared with placebo in double-blind studies [ Dean et al . 1999 ; Dodrill et al . 1993 ; Gillham et al . 1993 ] and fewer adverse effects than carbamazepine in a small, open-label, randomized, parallel-group study [ Kälviäinen et al . 1995 ]. Vigabatrin had no detrimental effects on cognitive functions at 12 months, and memory retrieval and mental flexibility improved significantly. One double-blind, placebo-controlled, randomized study reported impaired performance relating to motor speed and design learning in adolescents and adults with partial epilepsy [ Grunewald et al . 1994 ]. However, such negative effects were only reported in nonresponders who poorly tolerated the drug. There was also evidence of the development of tolerance in relation to CAEs. Overall, vigabatrin monotherapy seems well tolerated in relation to cognition [ Monaco et al . 1997 ; Provinciali et al . 1996 ; Ylinen et al . 1995 ], including in patients with intellectual disability [ Ylinen, 1998 ].

In a double-blind study involving 100 adult epilepsy patients, 52 taking vigabatrin and the rest placebo [ Guberman and Bruni, 2000 ], there was a tendency for improvement on most tests of cognitive function: 15 showed improvement, one showed no change, and scores worsened for five tests. Other studies report improved cognition in children [ Camposano et al . 2008 ] and in 66% of patients with epilepsy and psychosis [ Veggiotti et al . 1999 ]. Improvements include better episodic memory, semantic memory and flexibility of mental processing in adolescents and adults [ Kälviäinen et al . 1995 ] and decreased arithmetic response time [ McGuire et al . 1992 ].

The main limitation with the use of vigabatrin is visual field constriction, which may affect 30–50% of patients [ Gonzalez et al . 2006 ]. The prevalence of such difficulties may be lower in children than in adults, and the cumulative dose of vigabatrin or length of treatment may add to the personal predisposition for developing visual field constriction [ Vanhatalo et al . 2002 ]. Caution in prescribing is merited, given reports of slowed response time linked to visual processing during use and possible difficulties detecting peripheral moving objects, which have implications for driving [ Naili et al . 2009 ].

One study reported no difference between the performance of patients taking clobazam or carbamazepine on tests assessing intelligence, memory, attention, psychomotor speed, and impulsivity [ Bawden et al . 1999 ]. There was little evidence of CAEs in an open study involving children [ Jan and Shaabat, 2000 ]. In another study involving children, attention and alertness improved with clobazam [ Munn and Farrell, 1993 ]. Although 72% reported improvements in cognition, 26% reported deterioration in at least one aspect of cognition. An open study of adolescents and adults [ Montenegro et al . 2001 ] identified CAEs in just two of 97 patients.

Although CAEs are often the most common reason for discontinuation of zonisamide, perhaps only 5.8% will withdraw from treatment for this reason [ White et al . 2010 ]. There are conflicting findings as to the prevalence of CAEs. One retrospective analysis showed memory loss in 35% and attentional problems in 27% of 60 patients [ Park et al . 2007 ], while other reports indicate cognitive problems in 4–12% of children [ Kothare et al . 2006 ; Kim et al . 2005 ]. Berent and colleagues reported difficulties with learning in association with zonisamide in a small, add-on study [ Berent et al . 1987 ]. Cognitive difficulties were also reported by an open-label investigation [ Park et al . 1999 ]. After 1 year of treatment, 16 patients (47%) complained of cognitive deficits. Worse performance was apparent in tasks involving attention, memory and verbal fluency, and was related to dose. These authors concluded that zonisamide has adverse effects on cognition, even after 1 year of treatment.

Most studies tend to report little or no cognitive impairment in association with gabapentin, including double-blind studies [ Dodrill et al . 1999 ; Meador et al . 1999 ; Leach et al . 1997 ], and there may be potential for improved performance in cognitive measures [ Mortimore et al . 1998 ].

In one study, only 4% of patients taking pregabalin reported cognitive problems [ Valentin et al . 2009 ]. When present, possible CAEs include deterioration in verbal and visual episodic memory [ Ciesielski et al . 2006 ]. One double-blind, randomized, placebo-controlled study involving a large sample of adolescents and adults with partial epilepsy [ French et al . 2003 ] reported abnormal thinking in 2% of the placebo group, compared with 3.4% of patients taking 50 mg pregabalin, 7% taking 150 mg, 7.8% taking 300 mg and 4.5% taking 600 mg. An open study of add-on pregabalin noted few reported CAEs [ Jan et al . 2009 ]. Other reports indicate that abnormal thinking may be rare [ Arroyo et al . 2004 ], although one report indicated this CAE could be 9–12 times more likely with pregabalin than with placebo [ Beydoun et al . 2005 ].

Studies are listed in Table 2 . Reports indicate that CAEs are not uncommon with topiramate [ Bootsma et al . 2006 ], and may constitute a large proportion of the AEs in children [ Mohamed et al . 2000 ]. One study found 44% of patients reported experiencing CAEs after 1 year of treatment [ Lee et al . 2006 ]. However, a double-blind, randomized trial in older adults reported CAEs including memory worsening and language difficulties in only 1–5% of patients using topiramate [ Ramsay et al . 2008 ]. Whatever the frequency of CAEs, they are the most likely reason for treatment withdrawal [ Tatum et al . 2001 ].

Studies on the cognitive effects of topiramate in patients with epilepsy.

AEDs, antiepileptic drugs; CAEs, cognitive adverse effects; CBZ, carbamazepine; cont, controlled; DB, double-blind; ERP, event Related Potential; ETX, ethosuximide; GBP, gabapentin; HCs, healthy controls; LTG, lamotrigine; OL, open-label; OXC, oxcarbazepine; PAE, psychiatric adverse effects; PC, placebo-controlled; PHB, phenobarbital; PHT, phenytoin; rand, randomized; retro, retrospective; SB, single-blind; TPM, topiramate; VGB, vigabatrin; VPA, sodium valproate.

Cognitive side effects can include impaired concentration [ Froscher et al . 2005 ], cognitive dulling [ Coppola et al . 2002 ], psychomotor slowing [ Tatum et al . 2001 ], language and comprehension problems [ Fritz et al . 2005 ], detrimental effects on short-term memory [ Gomer et al . 2007 ; Aldenkamp et al . 2000 ] and working memory [ Jung et al . 2010 ; Lee et al . 2006 ; Fritz et al . 2005 ], poor verbal fluency [ Jung et al . 2010 ; Gomer et al . 2007 ; Lee et al . 2006 , 2003 ; Fritz et al . 2005 ; Thompson et al . 2000 ] and word-finding deficits [ Mula et al . 2003b ], reduced IQ score [ Sun et al . 2008 ; Lee et al . 2003 ; Thompson et al . 2000 ] and cognitive speed [ Bootsma et al . 2008a ; Gomer et al . 2007 ], and abnormal thinking [ Froscher et al . 2005 ]. Other studies report improvements in cognitive measures after topiramate withdrawal [ Kockelmann et al . 2003 ]. For example, in one study, verbal fluency, verbal and spatial span and attention improved after treatment withdrawal, and patients then performed similarly to untreated patient controls [ Kockelmann et al . 2003 ]. EEG changes may be seen in frontal regions, along with deterioration in cognitive performance [ Jung et al . 2010 ].

Topiramate has been shown to exert more negative effects on cognition than a range of other AEDs. Poorer verbal fluency, attention and inhibitory performance have been reported than with lamotrigine [ Blum et al . 2006 ; Kockelmann et al . 2004 ], and verbal fluency and working memory are also worse than with oxcarbazepine [ Kim et al . 2006 ]. Memory and attention effects may be worse than with valproate [ De Araujo Filhou et al . 2006 ], and verbal fluency, cognitive speed and short-term memory were worse than with levetiracetam in one study [ Gomer et al . 2007 ].

Although some studies argue that topiramate may be more commonly linked to CAEs, there are some reports indicating these effects are rather infrequent [ Brandl et al . 2010 ; Majkowski et al . 2005 ; Reith et al . 2003 ; Baker et al . 2002 ]. The rate of discontinuation due to CAEs may also be low, especially with low doses [ Arroyo et al . 2005 ]. In one study, more than half the children taking topiramate experienced adverse effects that could interfere with learning at school, but 20% demonstrated increased alertness or improved behaviour [ Moreland et al . 1999 ]. Reassuringly, CAEs tend to reverse with discontinuation [ Lee et al . 2006 ; Rosenfeld et al . 1997 ]. Studies have also indicated that certain individuals may be more vulnerable to CAEs with topiramate, including those with temporal lobe epilepsy [ Mula et al . 2003b ], existing cognitive difficulties [ Coppola et al . 2008 ] or a past psychiatric history [ Kanner et al . 2003 ].

Lamotrigine

Studies are listed in Table 3 . One double-blind, placebo-controlled crossover study of 81 patients with refractory partial seizures demonstrated no adverse effect on cognition in association with lamotrigine [ Smith et al . 1993 ], and other studies have reported similar findings [ Bootsma et al . 2008b ; Gillham et al . 2000 ; Aldenkamp et al . 1997 ]. For example, in a double-blind, placebo-controlled study involving children, there were no differences in the results of cognitive tasks assessing reaction time, recognition memory, attention, visual search and working memory [ Pressler et al . 2006 ]. Positive effects on cognitive function in epilepsy have also been reported [ Placidi et al . 2000 ; Banks and Beran, 1991 ]. Attention processes, short-term memory, and motor and mental speed were investigated in 25 epilepsy patients taking carbamazepine plus lamotrigine as add-on therapy [ Aldenkamp et al . 1997 ]. There were no significant score decreases after adding lamotrigine, and most changes were in a positive direction. It has been suggested that positive effects on cognition are related to EEG changes [ Marciani et al . 1998 ]. Lamotrigine has also been shown to have a favourable cognitive profile in comparison with other AEDs. Verbal fluency and attentional/inhibitory performance is better than with carbamazepine [ Lee et al . 2011 ], list learning may be better than with oxcarbazepine [ Seo et al . 2007 ], and a double-blind, randomized study of adults with partial seizures showed performance was better with lamotrigine than topiramate for verbal fluency, the Stroop test and the DSST [ Blum et al . 2006 ].

Studies on the cognitive effects of lamotrigine in patients with epilepsy.

Oxcarbazepine

Studies have indicated no deterioration in learning, memory or attention in patients treated with oxcarbazepine [ Donati et al . 2006 ; McKee et al . 1994 ], and little evidence of cognitive problems after 4–12 months of treatment [ Aikiä et al . 1992 ]. A multicentre, randomized, open-label study in children and adolescents reported little evidence of CAEs [ Donati et al . 2007 ], while another study involving children with benign epilepsy with centrotemporal spikes showed no deterioration in cognitive tasks, and evidence of mild improvement in some cases [ Tzitiridou et al . 2005 ]. One study documented improvement in an information processing speed task in patients with partial epilepsy [ Donati et al . 2006 ].

Levetiracetam

Studies are listed in Table 4 . In one study of patients with intractable epilepsy, levetiracetam was compared with topiramate [ Huang et al . 2008 ]. There were no significant differences in cognition for these AEDs, and no significant negative effects were reported with the use of levetiracetam in this study. Many other studies have reported no detrimental effects on cognition [ Levisohn et al . 2009 ; Huang et al . 2008 ; Gomer et al . 2007 ; Piazzini et al . 2006 ]. No significant changes in psychomotor function, memory or information processing were found in a study of 10 patients when levetiracetam was added to carbamazepine or phenytoin [ Neyens et al . 1995 ]. In fact, levetiracetam seemed to improve reaction time, tapping rate and memory.

Studies on the cognitive effects of levetiracetam in patients with epilepsy.

Other studies have reported improved cognitive functioning with levetiracetam. An open study reported improvements in cognition/behaviour in 10 of 39 children [ Wheless and Ng, 2002 ], while another study involving children with atypical benign childhood epilepsy found that 10 of 32 patients reported improvements in cognition, while the remainder stated no differences [ Von Stülpnagel et al . 2010 ]. One controlled study provided more conservative estimates of improvement [ Helmstaedter and Witt, 2010 ], reporting that executive functions improved in 15% but deteriorated in 5% of patients. Some studies report improved cognition according to quality-of-life scores [ Wu et al . 2009 ; Cramer et al . 2000 ].

Levetiracetam may have the potential to improve a range of cognitive abilities. These include visual short-term memory [ Ciesielski et al . 2006 ], working memory [ López-Góngora et al . 2008 ; Rosche et al . 2004 ], motor functions [ López-Góngora et al . 2008 ], psychomotor speed and concentration [ Helmstaedter et al . 2008 ], and fluid intelligence [ Rosche et al . 2004 ]. A randomized, double-blind, placebo-controlled study reported improved performance in set-shifting, attention and delayed logic memory tasks in patients with partial seizures in comparison with controls [ Zhou et al . 2008 ]. One study reported that improvements in prospective memory, working memory and motor functions were related to seizure reduction [ López-Góngora et al . 2008 ]. However, improvements in psychomotor speed, concentration and remote memory were not related to type of epilepsy, medication parameters or psychiatric history in another study [ Helmstaedter et al . 2008 ].

Individuals with existing cognitive weaknesses may benefit most from levetiracetam. A blinded study showed recent memory improved most in patients with poor baseline scores [ Huang et al . 2008 ]. In addition, at least two studies have reported improvements on the Mini-Mental State Examination with use [ Lippa et al . 2010 ; Wu et al . 2009 ], one of these in elderly patients with cognitive impairment [ Lippa et al . 2010 ].

Summary of study findings

The older agents likely to have the greatest cognitive toxic potential are phenobarbital and perhaps primidone. Carbamazepine has the potential to lead to mild but sometimes significant difficulties relating to motor speed and performance on more attention-demanding tasks. The cognitive effects associated with phenytoin may be more obvious but are generally restricted to visually guided motor functions. Minimal difficulties are also likely with sodium valproate taken at low doses. Further investigation is needed, but ethosuximide may be the older drug that shows the best cognitive profile.

With regards to newer drugs, topiramate is associated with more consistent evidence of detrimental influences on cognition. Little data are available at present for zonisamide, but findings so far indicate that adverse long-term effects are possible. Study findings for tiagabine are relatively promising, with the potential for positive effects on verbal fluency and visuomotor performance, although it is unclear whether these may be the result of seizure control. There is currently limited evidence of CAEs with the use of clobazam, and reported ‘abnormal thinking’ in association with pregabalin requires further specification. There is only limited evidence that vigabatrin interferes with cognition and this agent may exert a range of cognition-enhancing effects, including improvements in memory and mental flexibility. However, its use is restricted owing to reported visual field defects. More favourable options may include gabapentin and oxcarbazepine, which have been associated with only minor cognitive difficulties. Based on the evidence reviewed, the agents least likely to interfere with cognitive processes are levetiracetam and lamotrigine. The current review indicates the most consistent evidence of widespread positive effects on cognition is for levetiracetam, which may be particularly beneficial in cases with existing cognitive limitations.

Implications for clinical practice

Importantly, the data reviewed suggest that the effects exerted by an AED could vary depending on factors linked to patient characteristics and individual susceptibility. Although reported findings are mixed, many of these potentially influential treatment and patient variables clearly compel further investigation in more focused and rigorous experimental designs.

The amount of an AED administered, or AED combinations, may be linked to the incidence of cognitive effects. CAEs may be dose related for phenytoin [ Gillham et al . 1990 ], zonisamide [ Park et al . 1999 ] and carbamazepine [ Gillham et al . 1988 ], with the strongest evidence available for topiramate [ Kim et al . 2006 ; Lee et al . 2006 ; Froscher et al . 2005 ; Thompson et al . 2000 ]. However, other studies report no relationship between CAEs and dose for valproate [ Ristic et al . 2006 ; Gillham et al . 1991 ], topiramate [ Kockelmann et al . 2004 ; Kockelmann et al . 2003 ; Gerber et al . 2000 ] and levetiracetam [ Helmstaedter et al . 2008 ; Gomer et al . 2007 ]. Drug concentration has been linked to CAEs for valproate [ Forsythe et al . 1991 ; Galassi et al . 1990 ], carbamazepine [ Gillham et al . 1988 ; O’Dougherty et al . 1987 ] and topiramate [ Froscher et al . 2005 ]. Other studies have reported no such association for valproate [ Brouwer et al . 1992 ], topiramate [ Kockelmann et al . 2003 ] and phenobarbital [ Manni et al . 1993 ]. Titration rate is also potentially influential, and there is mixed evidence regarding whether this factor may lead to increased risk of CAEs with topiramate [ Mula et al . 2003b ; Tatum et al . 2001 ; Aldenkamp et al . 2000 ].

The use of concurrent medications appears to increase the likelihood of CAEs with many AEDs such as valproate [ Gillham et al . 1991 ], carbamazepine [ Gillham et al . 1988 ] and topiramate [ Brandl et al . 2010 ; Mula et al . 2003b ], but is perhaps less relevant in relation to levetiracetam [ Helmstaedter et al . 2008 ]. Combining topiramate with lamotrigine led to an increased likelihood of cognitive problems in one study [ Gerber et al . 2000 ].

Certain individuals may be more vulnerable to the CAEs associated with particular AEDs. These include refractory cases, patients with different kinds of epilepsy and younger or older patients. One study of vigabatrin reported CAEs in a relatively limited set of individuals classified as nonresponders [ Grunewald et al . 1994 ], although the characteristics of these individuals were poorly specified. Improvements in seizure control are particularly important in relation to attributing the cause of positive effects on cognition. In relation to levetiracetam, some studies report associations between enhanced cognition and seizure reduction [ Von Stülpnagel et al . 2010 ], while others argue improvements may be independent of seizure reduction [ Wheless and Ng, 2002 ]. Although AEDs such as topiramate and carbamazepine could have the potential to affect cognitive function in a wide variety of cases, some studies have reported that temporal lobe epilepsy may be a risk factor for the development of CAEs [ Mula et al . 2003a , 2003b ; Gigli et al . 1996 ]. Word-finding difficulties in particular have been linked to the presence of simple partial seizures and left temporal EEG focus [ Mula et al . 2003b ]. There is little evidence that patients with a longer history of epilepsy are more likely to be susceptible to CAEs with sodium valproate [ Ristic et al . 2006 ; Galassi et al . 1990 ], although duration of drug intake has been shown to be a related factor for CAEs with carbamazepine [ Shehata et al . 2009 ]. Age has sometimes been shown to be unrelated to the presence of CAEs [ Ristic et al . 2006 ], but is likely to play a role in the expression of cognitive difficulties, and one complicating factor in the examination of age effects is the use of differing instruments with individuals of different age groups.

Current or previous cognitive or psychiatric problems may also be linked to the cognitive effects of an AED. With topiramate, CAEs may be most likely in individuals with intellectual disability [ Coppola et al . 2008 ] or previous cognitive difficulties [ Gerber et al . 2000 ]. Other risk factors associated with the use of topiramate in adults include the occurrence of psychiatric adverse events and having a past psychiatric history [ Kanner et al . 2003 ], and depression and hippocampal sclerosis in temporal lobe epilepsy [ Mula et al . 2003a ]. In relation to levetiracetam, one study reported that psychiatric history was not associated with cognitive effects [ Helmstaedter et al . 2008 ], although another report indicated this agent could be more likely to lead to cognitive improvements in cases with existing cognitive difficulties [ Huang et al . 2008 ].

Limitations and recommendations for future research

Particular AEDs may have greater potential for negative or beneficial impacts on cognition in epilepsy, and these effects may be mediated by both treatment and patient characteristics. However, it is difficult to compare findings across studies owing to variation in study design, treatment group and assessment tools. Analysis is also limited by the availability of studies for particular agents. Many investigations have been conducted into agents including topiramate, whereas there are limited data available for AEDs such as ethosuximide and pregabalin.

There are significant difficulties relating to the consistency of available information pertaining to study methodology. Many studies fail to assess cognitive effects using a wide variety of tasks. Some reports fail to clearly indicate patient characteristics such as epilepsy type, seizure type or focus (left/right/frontal/temporal). Other useful information such as effect size is rarely available. Furthermore, many reports have failed to investigate predictive factors for the development of CAEs. Future studies should seek to determine whether reported changes in cognition are linked to drug efficacy in treating seizures rather that direct effects on cognition per se .

It can be particularly difficult to differentiate between AEDs on the basis of cognitive findings. In some cases there could be age-difference effects, which could partly reflect the assessment of children through behavioural observation and parent report, by comparison with older patients’ self report. The inclusion of different kinds of patient groups (e.g. treatment-naïve patients, refractory patients, patients with epilepsy after brain injury) and control measures (healthy individuals or nonmedicated patients; no treatment, placebo or alternative medication etc.) further complicate comparisons across studies. The CAEs reported by these studies will at least partly reflect the differing clinical characteristics and specific vulnerabilities of the groups compared.

Another problem relates to poor definitions of cognitive functions, and lack of consensus in the terms used to refer to cognitive abilities. Some studies refer to ‘mental processing speed’, others refer to ‘psychomotor speed’, and yet others use terms such as ‘information processing rate’. It is often unclear as to whether such descriptions refer to the same ability. Vague terms are also used, such as ‘cognitive dulling’ and ‘abnormal thinking’. These need to be better specified in order to be informative. In addition, particular tasks are sometimes reported as measuring slightly different cognitive abilities that are often closely linked, such as memory, learning and attention. For example, tasks such as the Stroop test may be considered to make demands in terms of attention, concentration, response inhibition and maybe even memory. Future studies need to use consistent, more precisely defined terms and consider the individual contributions of different cognitive abilities or processing stages involved in tasks and assessments.

A number of randomized, double-blind trials have been conducted. These studies appear favourable as they control for bias, although this approach could lack ecological validity. Add-on trials may be problematic because of a possible increase in the incidence of side effects due to the potentiation of toxicity. However, these studies do have value in relation to current prescribing practices, as many patients are only successfully treated with a combination of different AEDs. What may constitute a more rigorous investigation may provide data that are not so readily applicable in everyday clinical practice. Consistent evidence across studies using rigorous and more naturalistic methods will provide a good indication of the reliability of study findings.

More specific, systematic studies are needed to fill the gaps in our knowledge and follow up reported patterns in the literature about the cognitive effects linked to AEDs. Longer-term investigations would also offer critical insight, because individuals may gradually develop tolerance to an AED’s side effects. It is also informative for studies to investigate whether performance alters on discontinuation, in order to determine if effects are reversible. Systematic trials are needed that compare the effects of commonly prescribed agents across subgroups of patients with epilepsy (e.g. in partial versus generalized epilepsy). Comparing age-defined subgroups could also be useful, as drug effects are likely to differ between younger and older children.

A wide range of assessments clearly need to be included in future research. Studies investigating cognition should include tests of a range of executive functions including working memory; verbal fluency; response inhibition; set-shifting and measures assessing transient, sustained and divided attention; short and long-term aspects of verbal and visual memory; and motor functioning including dexterity and reaction time tests. One useful outcome of future research would be the identification or development of tailored instruments that are sensitive to the specific cognitive changes associated with particular AEDs.

Acknowledgments

The authors had no assistance with study design, data collection, data analysis or manuscript preparation.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

The authors declare no conflicts of interest in preparing this article.

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Sleep apnea symptoms linked to memory and thinking problems

P eople who experience sleep apnea may be more likely to also have memory or thinking problems, according to a preliminary study that will be presented at the American Academy of Neurology's 76th Annual Meeting taking place April 13–18, 2024, in person in Denver and online. The study shows a positive association but did not determine whether sleep apnea causes cognitive decline.

Sleep apnea is when people stop and restart breathing repeatedly during sleep which can lower oxygen levels in the blood. Symptoms include snorting, gasping and breathing pauses. People with the disorder may also experience morning headaches or have trouble focusing on tasks.

"Sleep apnea is a common disorder that is often underdiagnosed, yet treatments are available," said study author Dominique Low, MD, MPH, of Boston Medical Center in Massachusetts, and a member of the American Academy of Neurology. "Our study found participants who had sleep apnea symptoms had greater odds of having memory or thinking problems."

The study involved 4,257 people. Participants completed a questionnaire asking about sleep quality as well as memory and thinking problems. For sleep, participants were asked about snorting, gasping or breathing pauses in their sleep. For memory and thinking, participants were asked questions related to difficulty remembering, periods of confusion, difficulty concentrating or problems with decision making.

Of all participants, 1,079 reported symptoms of sleep apnea. Of those with symptoms, 357 people, or 33%, reported memory or thinking problems compared to 628 people, or 20% of people without sleep apnea symptoms.

After adjusting for other factors that could affect memory and thinking problems, such as age, race, gender and education, researchers found that people who reported sleep apnea symptoms were about 50% more likely to also report having memory or thinking problems compared to people who did not have sleep apnea symptoms.

"These findings highlight the importance of early screening for sleep apnea," said Low. "Effective treatments like continuous positive airway pressure (CPAP) machines are readily available. Quality sleep, along with eating a healthy diet, regular exercise, social engagement and cognitive stimulation, may ultimately reduce a person's risk of thinking and memory problems, improving their quality of life."

Limitations of the study include that the data was sourced from one survey and participants reported their symptoms instead of being assessed by medical professionals. Additional studies are needed following people's sleep apnea, memory and thinking symptoms over time.

Provided by American Academy of Neurology

Patient Care & Health Information
Diseases & Conditions

Auditory processing disorder (APD)

Auditory processing disorder, also called APD, is a type of hearing loss caused by something affecting the part of the brain that processes how you hear. Ear damage causes other types of hearing loss.

APD is also sometimes called central auditory processing disorder (CAPD). It can happen in anyone. But it most often happens in children and older adults.

Many conditions can affect how well a person understands what they hear, such as attention-deficit/hyperactivity disorder (ADHD) or autism. But these conditions are different from auditory processing disorder, although they can appear with APD . APD also can happen with other types of hearing loss.

Auditory processing disorder has no cure. But treatments can help you hear better.

Symptoms of auditory processing disorder (APD) can be subtle. Symptoms can include having trouble with:

Telling where sound is coming from.
Understanding words that are spoken quickly or in a noisy room.
Paying attention.
Reading and spelling.
Following directions unless they are short and simple.
Learning a new language.
Singing or enjoying music.
Understanding and remembering spoken information.

If you have APD , you also might:

Take longer to reply to someone who is talking to you.
Often need others to repeat themselves.
Not understand sarcasm or jokes.

APD is often seen with attention, language and learning issues like those seen in attention-deficit/hyperactivity disorder, or ADHD.

When to see a doctor

If you have trouble hearing or understanding what you hear, talk to a health care professional.

The cause of auditory processing disorder (APD) is sometimes unknown. APD can be linked to many conditions. In older adults, conditions might include stroke and head trauma. In children, APD can be linked to issues at birth, such as low birth weight or early birth, or repeated ear infections.

In typical hearing, the brain's auditory center takes the sound waves sent from the ears and turns them into sounds you know. But with auditory processing disorder (APD), the auditory part of the brain can't do this.

Risk factors

Factors that increase your risk of auditory processing disorder (APD) include:

Head trauma.
Lead poisoning.
Seizure disorders.
Issues linked to birth, such as an early birth, low birth weight or a pregnant person using alcohol, drugs or tobacco.
Repeated ear infections, especially at a young age.

Complications

Auditory processing disorder (APD) complications include:

Trouble understanding what people are saying.
Trouble taking part in activities.
Feeling isolated and lonely.
Trouble reading and writing, in children.
Trouble doing well in school.
Feeling depressed.
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Understanding auditory processing disorders in children. American Speech-Language-Hearing Association. https://www.asha.org/public/hearing/understanding-auditory-processing-disorders-in-children/. Accessed June 22, 2023.
Cifu DX, et al., eds. Auditory, vestibular and visual impairments. In: Braddom's Physical Medicine and Rehabilitation. 6th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed June 22, 2023.
Liu P, et al. Electrophysiological screening for children with suspected auditory processing disorder: A systematic review. Frontiers in Neurology. 2021; doi:10.3389/fneur.2021.692840.
Sardone R, et al. The age-related central auditory processing disorder: Silent impairment of the cognitive ear. Frontiers in Neuroscience. 2019; doi:10.3389/fnins.2019.00619.
Central Auditory Processing Disorder. American Speech-Language-Hearing Association. https://www.asha.org/practice-portal/clinical-topics/central-auditory-processing-disorder/. Accessed June 22, 2023.
Health Education & Content Services. Auditory processing disorder. Mayo Clinic; 2023.
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Auditory processing disorder (APD)
Symptoms of auditory processing disorder (APD) can be subtle. Symptoms can include having trouble with: Telling where sound is coming from. Understanding words that are spoken quickly or in a noisy room. Paying attention. Reading and spelling. Following directions unless they are short and simple. Learning a new language.